Opioid-Related Death Crisis Leads to New Guidelines

The Commonwealth of Pennsylvania has rolled out voluntary guidelines for opioid prescribing intended for emergency departments, pharmacists, dentists, and geriatric care providers.

ORLANDO — At the annual meeting of the American Academy of Pain Medicine (AAPM), Rachel L. Levine, MD, Physician General for the Commonwealth of Pennsylvania and professor of pediatrics and psychiatry at the Pennsylvania State College of Medicine, gave the keynote address titled “The Prescription Opioid and Heroin Crisis: A Public Health Response,” in line with this year's conference theme.1

With more than 3500 prescription opioid-related deaths occurring in the state of Pennsylvania in 2015 — reflecting a 30% increase from the previous year — this issue represents a significant public health crisis. The Commonwealth has therefore adopted a multipronged approach to stem the tide. In collaboration with numerous professional stakeholders, the state has rolled out voluntary guidelines for opioid prescribing intended for emergency departments, pharmacists, dentists, and geriatric care providers, among others. “Guidelines have an excellent ability to change behaviors, even if they are voluntary,” said Dr Levine.

As 48 states in the United States have developed comprehensive prescription drug monitoring programs (PDMPs), one can learn best practices from other states. Thus, in the summer of 2016, a PDMP was rolled out in Pennsylvania. PDMPs in other states have statewide databases are available for dispensers to register the dispensing of any controlled substance. Medical providers are required to check the database every time they write a prescription for opioids or benzodiazepines. If the database indicates that a patient has been going from physician to physician for opioid prescriptions, providers can intervene. “What happens next is absolutely critical,” said Dr Levine. If the medical provider refuses to prescribe opioids to the patient, “that person will go down the street and buy a bag of heroin for around $5,” she added. To avoid this issue, the Commonwealth has been trying to push “warm hand-offs” as part of a facilitated referral for treatment.

Although naloxone has been an effective opioid-reversal tool for decades, the community use of this agent is a recent occurrence. In 2014, the legislative branch of the state of Pennsylvania passed a bill, Act 139, allowing first responders to carry naloxone and for physicians to write a third-party prescription for naloxone. In 2015, as physician-general, Dr Levine wrote 2 standing-order prescriptions as physician-general, one for first responders and one for the general public (for intranasal and intramuscular naloxone). Since that time, the police of Pennsylvania have used naloxone to save more than 2400 lives. In addition, every public school in the state has 2 kits of naloxone available — each includes the nasal spray, the auto-injector, and the prefilled medication tube with an automization device. Several websites provide training for naloxone.

In addition, a firm “warm hand-off” clinical pathway — a facilitated referral protocol — has been developed for emergency departments. Another aspect of the Commonwealth's response to the opioid crisis lies in an emphasis on medication-assisted treatment (including methadone, buprenorphine, and long-acting naltrexone), with 45 centers of excellence spread throughout the state for patients on Medicaid. “Those medication-assisted treatments need to be paired with a treatment. One can't just write a prescription for buprenorphine and tell the patient to come back a month later,” remarks Dr Levine. The patient needs to be engaged in counseling and therapy, in addition to receiving medicine for withdrawal symptoms.

Finally, a take-back program was established to protect against diversion of unused opioid medication, with take-back days scheduled and take-back boxes located in most municipal police departments throughout the state.

“It is absolutely critically important that we all work together on this. This is a public health crisis, and that means that the executive and legislative branches of government need to work with all stakeholders, and the public, to deal with this crisis…It is so important to get rid of the stigma associated with addiction. Addiction is not a moral failing, but rather a disease,” concluded Dr Levine.